A miscarriage is the loss of a pregnancy before the 24th week. When this occurs two or more times consecutively, it is referred to as recurrent miscarriage or recurrent pregnancy loss (RPL), and it can affect both naturally conceived pregnancies and those achieved through IVF. This term does not encompass ectopic or molar pregnancies.
Recurrent miscarriage can stem from a variety of causes. Genetic factors, particularly chromosomal abnormalities in the embryo, are among the most common, accounting for many first-trimester losses. Uterine abnormalities, such as structural defects within the uterus, can also lead to recurrent pregnancy loss, as can cervical insufficiency, where the cervix weakens and opens prematurely, often resulting in second or third-trimester miscarriages. Blood clotting disorders, known as thrombophilias, can increase the risk of miscarriage by impairing blood flow to the placenta, and these conditions are typically managed with medications like aspirin and heparin. Additionally, lifestyle factors such as smoking, alcohol use, environmental exposures, and advanced maternal age can elevate the risk of miscarriage. Despite thorough testing, around half of all recurrent miscarriages remain unexplained.
After two consecutive miscarriages, it is critical for couples to undergo a comprehensive evaluation to determine the underlying cause of their recurrent pregnancy loss. This assessment usually includes several diagnostic tests: Parental Karyotyping to detect chromosomal abnormalities in either partner; a Hysterosalpingogram (HSG) to assess the uterus and fallopian tubes for structural issues; Hysteroscopy for direct visualization of the uterine cavity; and Transvaginal Ultrasound to evaluate the uterus and ovaries. In addition, an Endometrial Biopsy may be conducted to assess the health of the uterine lining, while Sperm DNA Fragmentation Testing examines the integrity of the sperm’s DNA. Blood tests are also crucial, including Thrombophilia Testing to identify clotting disorders and Endocrine Testing to measure hormone levels such as thyroid hormones, progesterone, prolactin, and blood sugar. Vitamin levels, including folic acid, B12, Vitamin D, and homocysteine, are also assessed, as they are vital for a healthy pregnancy.
Treatment for recurrent miscarriage is highly personalized and depends on the woman’s age and the specific cause of the miscarriages. Some potential treatment options include:
Surgical Correction: For uterine anomalies, surgery may be recommended to correct structural issues.
IVF with Preimplantation Genetic Testing (PGT): For couples with chromosomal abnormalities or advanced maternal age, IVF combined with PGT can help ensure that only chromosomally normal embryos are transferred, thereby reducing the risk of miscarriage.
Cervical Cerclage: For cervical insufficiency, a cerclage procedure may be performed to prevent premature cervical opening.
Hormone Therapy: For endocrine problems, hormone therapy may be prescribed to support the pregnancy.
Before starting treatment, it is essential to thoroughly investigate the causes of recurrent miscarriage to tailor the most effective treatment plan for the couple.
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